2

Learning Strategies for Medical

Students

Contents
1. Introduction
2. Learning to Learn
3. Characteristics of Medical School
4. Survival Strategies for Medical School
5. Learning Strategies
6. Learning Style
7. Strategic Learning & Study Skills
8. Steps to Strategic Learning
9. Text Review: A Strategic Method
10. Elaboration Techniques for Learning
11. Tips for Specific Learning Situations
12. Small Group Tutorials
13. Concept Mapping
14. Semantic Qualifiers
15. Test Taking Strategies & Tips
16. To Review: General Tips
17. Additional Points to Ponder
18. Students, Stress & Learning
19. Test & other anxiety
20. Learning Disability
21. Intercultural Communication
22. Glossary
 3

• Introduction
Bravo, you’re a medical student! This ebook is a selection of advice
and learning strategies to support your efforts to succeed in this
academic environment whether you’re a new med student or an
experienced med student or even a doctor. You and your fellow
students come to medical school with a varied pre-professional
background, and varied ambitions for professional practice, but all
are drawn together with a common interest in science, medicine, and
the healing arts.
Understanding the manners you learn best and how your learning
styles can be accommodated in medical school can help with
adjustment to the particular medical school curriculum, and help to
prevent problems with course work. Ideas in this ebook are offered as
learning strategies, strategic learning methods and suggestions to help
clarify your approaches to learning.

• Learning to Learn

or perfecting your learning style for medical school

It will not come as a surprise to serious students that the process of

learning itself must be learned. However, after years of formal
schooling, many students enter higher education and graduate
programs without having mastered these fundamental skills. When
you begin professional programs and are propelled into a more active
learner mode, understanding of these fundamentals becomes vital.
People learn how to learn through many avenues, such as modeling,
curiosity, and situational need. The outline provided on these pages is
intended as a way to help you understand the process of your
learning.
 4

The ideal learner

• Possesses a high motivation to learn 


• Has the ability to learn 


• Has the ability to retain and retrieve knowledge 


• Possesses a fair amount of self knowledge 


• Possesses a foundation of knowledge necessary for understanding

new material 


• Possesses cognitive strategies for learning, such as problem solving

skills, concept acquisition skills, and discrimination learning skills


Everyone uses an array of learning styles and skills that are the
preferred way to take in and process new information. Learning style
includes the specific and personal learning skills of reading, listening,
writing, coding; and the learning processes of reflection, trail and
error, or repetition.



Fundamentals of the learning how to learn process

This is a continuous ,lifelong, endeavor involving change and the

usual accompanying fear of change. It can be a frustrating
experience, yet when the next time a similar learning situation arises
you'll have the experience, confidence, and knowledge to make the
learning experience seem more effortless.
 5

Self awareness is a major component of this process. You need to

develop awareness of your preferred learning environment. What
resources can you draw upon and use for goal setting and monitoring
this effort toward reaching your goals? See Learning Strategies (p.12)
and Strategic Learning & Study Skills (p.18), in this ebook.

Cognitive learning to learn skills

• Develop critical evaluation skills. 


• Develop an appreciation for the “organizing circumstance” which

caused the need to learn something new or to learn in a new way. 


• Develop thinking skills:

- Convergently: synthesizes incoming information

- Divergently: making lateral connections, creative thinking
- Critically-analytical: focuses on major points, where the
information comes from, why the information affects the learner, or
their work and how, also looking at the parts involved.

- Intuitively: understanding the connectedness between concepts,

and the larger or intended meaning involved or implied.

• Learn for understanding, integrate concepts and learn the

relationships between concepts.

• Above all, don’t try to memorize everything!

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• Characteristics of Medical School

Characteristic Explanation
Important basic concepts from biology,
chemistry, anatomy, physiology, physics,
New material is based on and mathematics are the foundation of
old medical training. Organ system blocks use
cumulative acquisition of knowledge.
Tutorials build on existing knowledge.
Presented at once, all semester long, and
High volume of material in each course or block.
At the beginning you will become
acquainted with normal and pathological
mechanisms and their clinical
presentations, this includes laboratory, x-
Study to understand
ray, and other diagnostic testing and
pharmaceuticals. Use this information to
build deep understanding of concepts and
the relationship between concepts.
Independent work— Active learning: students are encouraged
Problem- Based Learning to coordinate their own learning
in small group student- opportunities, engage in the necessary
centered tutorials, case research and independent study to
study method, research, participate fully in problem solving efforts
peer teaching and related to the lecture, lab and clinical case
learning. based curriculum.
Learning and understanding the
mechanisms of health and disease in their
Clinical focus
clinical aspects helps you focus on your
goal of medical practice.
 7

Students use computers to communicate,

track course work, and for locating and
Computer adeptness
processing primary research and other
resources.
Personal responsibility for the appropriate
Internal Locus of Control acquisition of knowledge for successful
medical practice, motivation to learn.
Professional behavior and attitudes,
Ethical Behavior sensitivity to patients and their families,
confidentiality, respect, integrity, honesty.
 8

• Survival Strategies for Medical

School
Strategy Explanation
You should hear lectures and presentations first
hand to receive full benefit. Don’t depend on
other student’s notes because each student
Attend every class writes down and organizes concepts according
to what’s important to them.
Tutorial attendance is required, come prepared!
Study a modest number of hours most days and
avoid extremely long stretches of study because
Keep up with the work...
memory and retention diminish. Develop a
but pace yourself
regular review schedule; 1 day, 7 days, then 28
days.
Most instructors prefer students to clarify points
in class, this gives the instructor a chance to
elaborate on unclear points while the class is in
Clarify when you have
session. Students should regularly use office
questions
hours and/or make appointments to meet
personally with the instructor. Faculty are
generally very responsive to e-mailed questions.
This skill is related to your personality and
Get organized learning style. Learn to make the most of your
individuality, and particular study habits.
Medical school requires excellent time
management skills because of the volume of
work, and necessity to balance reading and
Manage your time research with clinical duties. Build in time for
personal pursuits and family.
(See Sample Time Management Plan)
Some experimentation with study space, time,
and environment is productive, but as soon as
possible you should establish a routine. The
Establish a study routine study environment has important psychological
triggers for learning.
This must include a schedule for reviewing.
 9

Get to know your faculty advisor, and other

See your faculty advisor medical school faculty and staff. Know who the
advisors are and how to contact them.
Choose a mentor, someone who you relate to
that can validate your medical school
Find a mentor
experience. A compatible faculty member,
senior medical student, or staff member.
Don’t be afraid to ask questions. The medical
Ask questions school is full of professionals willing, ready, and
able to help you succeed.
Once your academic performance is secure,
consider joining a student organization.
Professional Development Participate in event planning as an officer.
Leadership development leads to professional
development.

Sample Time Management Plan

• Look at your usual work patterns and identify high, medium, and
low concentration periods. 


• Create a semester calendar:


Include exact due dates, type of assignment or exam; clinical

schedule; also write in extra curricular activities, meetings, exercise,
personal time. 


• Make an outline of priorities for the whole semester. 


• Identify your most difficult work tasks and match them to your high 

concentration periods. 

 10

For example:



High concentration

writing, statistical analysis, research 


Moderate concentration

• Computations

• Memorization

• Assigned readings

• Editing and proofreading papers 


Low concentration

Rest, relaxation and recreation 


A word about "strategies"

Once you believe you are the agent of your success, you begin to
behave in ways that will produce that success.
Learning strategies, study strategies, test taking strategies… You have
successfully negotiated the vagaries of academic strategies in order to
get where you are today. Medical school is in some ways different
and unique, but not so unique that you can't build on past successes
to achieve your goals in medical school. As an adult learner, you'll
 11

notice a shift of responsibility from instructor-centered to student-

centered.
Research and practice has shown that adults learn best when
instruction is student-centered. Adult learners tend to exhibit the
following characteristics:

• ! Adults tend to be self-directing

• Adults bring many and various academic, work, and practical
experiences to the learning situation; these experiences can serve as
a rich source of learning resources

• Adults often bring a salience to the learning situation because of a

life, task, or problem-centered orientation to learning as opposed to
a subject-matter orientation.

• Adults usually are motivated to learn due to internal or intrinsic

factors (desire to achieve, to know) rather than external or extrinsic
forces (such as salary, recognitions).
Developing a strategy to ensure your own success will take some of
the uncertainty out of the medical school experience.
 12

• Learning Strategies
Strategy Explanation
Become acquainted
with your learning (See Learning Style: A, B,& C, next pages)
style.
Understand yourself as a learner, recognize
that your style of learning may not fit every
Identify your learning learning situation appropriately. Learn to
habits, monitor and monitor your study strategies for every course
adjust them as and adjust when necessary. Communicate your
needed. environmental study needs, such as quiet,
background music/noise, group or individual
study space.
Learning strategies that worked in
undergraduate course work can be retained.
Be alert to problems such as too much to
learn, not enough time, unexpectedly low
If it works, keep
grades on tests. These signal that your old
doing it.
methods may not be working in medical
school. If it isn't working, don't just do more of
the same thing. Seek assistance in developing
strategies that will work for you now.
Strategies for learning course material should
be geared toward each particular course
Approach each content and expected mode of assessment
course individually. (such as multiple choice, short answer, essay,
factual content, case study, clinical
performance).
Reviewing material in a group can be very
useful because it builds on the approaches &
Use study groups for
understanding developed by different students.
review.
The initial approach to understanding new
material is best undertaken individually.
 13

Tests and the grades they generate can be

Use test grades to considered tools for adjusting your study
build learning skill. strategies. You can review incorrect answers to
discover where understanding lapsed.
Active and purposeful study geared toward
Practice, practice, particular test type, along with adequate
practice. practice, can reduce performance anxiety (also
see Points to Ponder (in this ebook).

• Learning Style
Learning Style: A
A basic part of understanding the learning process is to think critically
about the way you learn. What are your most successful approaches
to conquering course work? When you understand your preferred
learning styles, you can bring a greater sense of control and flexibility
to the demands of each course as required.
The following categories suggest learning styles, but are actually
learning modalities. Everyone uses these in different circumstances,
but most people also have a favorite or preferred modality.

Style Characteristics
Learning by touch, by doing, by movement, by
Kinesthetic
involvement
Auditory Learning by hearing, speaking, listening
Linguistic Learning by reading about it, talking about it
Learning by forming mental pictures, by devising
Visual
diagrams and concept maps
Olfactory Learning by incorporating scent, association, memory
 14

You can learn to draw upon several learning styles and modalities,
trying a different style and studying approach to new material, as
learning situations warrant.

Learning Style: B
Another way of identifying learning preference is the dichotomy of
cognitive styles known as field dependent and field independent.
These cognitive styles describe the way people process information.
Students who are field independent rely on internal cues for the
processing of information, analyzing things into parts: these students
easily work independently. Field dependent students rely more
heavily on external stimuli in a task; they learn best with a group, and
may have difficulty separating individual parts from the whole.
These differences are important to understand in the context of
adaptation to medical school. Self knowledge will help to identify
learning and training needs and therefore find compatible learning
situations. As a field dependent student you may find study groups
bridge gaps between instructor distance and your preference for
interactive learning. Look for well articulated course objectives,
requirements, and class discussions. As a field independent student,
you can more easily structure your time independently, and may
appreciate designing your own assignments and assessments.
Independent study sessions are usually preferred.
You can identify your learning style preference through simple
reflection on your ideal learning situations. It is also important to
recognize that each faculty member has their own learning style and
therefore teaching style. Instructors often present course material
using their own preferred style. The subsequent kind of syllabus and
listing of course objectives, tests and other assignments, timelines for
course work completion, kinds of class discussions, desire to arrange
tutoring and review sessions, all reflect that style preference. As you
become familiar with learning and teaching style, seek out and
develop the most comfortable and effective balance necessary for
your academic success.
 15

Learning Style: C
It is also helpful to look at learning style in relation to personality-
based preferences. The Myers Briggs Type Indicator (MBTI) identifies
one's preferences for ways of taking in and processing information,
this describes aspects of both personality and learning style. The Type
Indicator is based on the work of Katharine Briggs and Isabel Briggs
Myers who wanted to make practical the theories of psychologist Carl
Jung. Personality, who you are and how you relate to others, impacts
learning style because basic preferences for relating to the world are
manifest in preferences for learning about the world. Attending to
your natural preferences can greatly facilitate understanding, memory,
retention, and retrieval.

The dichotomous scales as developed by Isabel Briggs Myers,

(McCaulley, 2001) are:

Attitudes Extroversion (E) Introversion (I)

Perceiving Function Sensing (S) Intuition (N)
Judging Function Thinking (T) Feeling (F)
Judging (J) Perceiving (P)

The type emerging from the Indicator is characterized with a main

preference in each of the four function categories, identified using the
designated letters, such as ISFJ. Knowing your personal type can
provide you with important information about how you might be
used to and most comfortable processing new information. The
descriptions on the following pages may offer some clues both about
your learning preferences, insight into how others learn, and ideas
about adding strategies. One way learning style manifests is with the
"perceiving function" of sensing (S) or intuition (N). Stated differently,
this function usually indicates a preference for linear learning or
integrative learning; linear being the structured outlined, detail
orientation, and integrative being the overview, big picture,
 16

conceptual version. You can see how both orientations will together
give you the foundation for medical education and practice.
Beyond the classroom, this understanding may prove useful for good
communication in tutorial groups, and clinical settings with health
care team members, patients and families.

Ways to use learning style to your advantage

Preferen Defining Characteristic Learning Advice

ce Characteristic Learning Style
Find energy in 1.“Chunk” groups of
Learn by explaining to
Extroversi things & people, inter- related
others. Learn well in
on prefer interaction knowledge/
groups.
with others. information.
2.Learn to group data.
3. Learn to recognize
Find energy in Learn by developing conceptual
Introversi inner world of connections & relationships.
on ideas, concepts, relationships between
4. Build compare/
and abstractions. concepts.
contrast tables;
flowcharts; and
concept maps to
illustrate.
Prefer organized, 1. Use of group study.
linear, instructional
lectures and 2. Case study method
Detail oriented, integrates needs of
handouts. Look for
Sensing look for facts, both: general
advance organizers.
trust facts. principles & detailed
Case study: prefer
Application, Theory, mechanisms.
Application.
 17

Prefer to focus on the

integrating framework,
Look for patterns
the “big picture.”
and relationships
Intuition among facts, trust "Whymethod."

Case study: prefer
intuition.
Theory, Application,
theory.

Decisions based 1. Match course and/

on impersonal or tutorial case
analysis, logic, Prefer clear, concise objectives to know
Thinking principle.
 course topics & action what you will be
Value: fairness, oriented objectives. tested on.
look for objective
criteria. 2. Pay attention to
group process in
tutorials, keep good
Decisions based
communication.
on personal
Prefer group work,
values, potential.
 3. Recognize the need
instructors can
Value: harmony, to integrate the
Feeling provide guidelines to
look for different levels of
facilitate group
consensus, good learning: rote
process.
at persuasion & memorization,
facilitation. integrated meaning,
and critical thinking.

Decisive, self- Note taking and test

Prefer to limit input
Judging regulated. Quick taking:
and make decisions.
to action.
 18

1.Use speedwriting
(omit vowels)


2.Split Page lecture

Curious, Prefer to gather more notes with follow-up
Perceivin
adaptable, data, wait to draw rewrite in own words.
g
spontaneous. conclusions.
3.Color Coding notes


4. Anticipate and
follow assignment
deadlines.

• Strategic Learning & Study Skills

Study Strategies Explanation
Be strategic in
developing See Strategic Learning, next pages
learning skills
See Survey, Question, Read, Recall, Review (text
Reading
review, p.19) Be selective, take note of text
textbooks--
headings, subheadings, bold and italic print, this
preview, review.
shows what the author considered important.
Highlight text with
Question while reading; What is this related to?
markers--using
Why do I need to know this? Write notes and
different colors
questions in margins when reading. Read for
and scents
understanding. Highlight for outlining later.
 19

Use a notebook with a line down the center; on

the right put class notes, on the left write your
own questions and clarifications.

Take time to relate notes to text. Rewrite and
Review.

Compare your “important points” with those of
Class notes
other students. Try writing notes, formulas,
concepts, memorization material on “butcher
paper” or “newsprint,” tape paper to walls and
study it by walking around. Highlight portions
that become committed to memory. Review,
review, review!!
Create concept To illustrate important concepts in material, good
maps. Use for showing relationships between concepts.
diagrams, charts, Good visual connections.
graphs (see Concept Mapping, p.30)
Review often. Good for memorization. Make sure
Note cards
information is accurate!
Good for visual learners. Use Roman numerals in
Outline: text and
an outline format, then review the outline. Use
class notes
highlighted text from text review.
Study as if you
This focuses your study time and allows you to
were teaching the
internalize new information sooner.
lecture.
Can be used as study group review, or self
Prepare a list of review. The learning process involved in
test questions. preparing questions promotes thoughtful long-
term learning.

• Steps to Strategic Learning

1. Set realistic learning goals
 20

These goals serve as the driving force “to generate and maintain the
motivation, thoughts, and behaviors” necessary to succeed.


Set and use long-term occupational goals (you want to be a doctor)

and short-term learning goals (you want to understand this new
material).

2. Types of knowledge needed to be a strategic learner

• Know yourself as a learner (learning preferences, talents, best

times of day to study, ability to match study skills to learning task);
this knowledge helps you set realistic yet challenging learning
goals.

• Knowing the nature and requirements of different types of

educational tasks.

• Knowing a variety of study skills and learning strategies and how to

use them.

• Knowing the contexts in which what is being learned can be used

now or in the future.



3. Use a variety of learning strategies

• Manage your study environment


• Coordinate study and learning activities


• Keep your motivation for learning clear


• Generate positive behaviors toward learning


 21

• Make new information meaningful to you


• Organize and integrate new information with existing knowledge,

or reorganize existing knowledge to fit the new understanding and 

information. 


• Place new information in a present or future context: 


How will it be used?

• Text Review: A Strategic Reading

for Understanding Method

Survey, Question, Read, Recall, Review

The "foundation approach" also known as SQ3R is outlined below.

A. Survey the text chapter by reading the headings, sub-headings,

and boldface print, then based on this survey of the text... 


B. Develop questions: write out questions remaining concerning the

text material. 


C. Read the text, trying to answer the questions generated earlier 


D. Recall the materials read with the book closed. 


E. Review the material with the book open. 


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Study support strategies

Both Primary and secondary support strategies are sometimes needed.
Primary strategies are those that you use to learn the material directly;
support strategies are used to keep focused.

A. Strategies for comprehension and retention

To help you reorganize, integrate, and elaborate the new material:

• Set the mood to study

• Read for understanding by highlighting, marking important points

• Recall material without referring to the text
• Correct recall, amplifying material to digest
• Expand knowledge by self-inquiry
• Review mistakes (learn from tests)
• Repeat , mentally process the same material more than once using
active recall, also process the information by putting the material
into an alternate form such as 19 your own words, or another
symbol system like concept maps.

More on strategies for comprehension & retention...

Understand strategy


On first pass: mark spots you do not understand


On second pass: focus on marked areas you still don’t understand,


 23

Then
• A. Identify why you don’t understand (words, sentences, paragraph)
• B. Break the problem down into parts, look at the surrounding text
for clues

• C. Check other resources

Recall strategies


After the initial reading:
A. Paraphrase and use imagery. Periodically when reading re-phrase
the new material and try to form mental pictures of the concepts.
B. Networking means transforming the material into concept maps, or
“networks”; you organize important concepts and represent their
interrelationships in a “network map.” (see Concept Mapping)


You can use pre-set named links to code these relationships. For
example, the categories of:
hierarchies (type)

chains (lines of reasoning)

clusters (characteristics, definitions)
C. Identify key concepts, develop systematic definitions and
elaborations of concepts, like the interrelationship between pairs of
concepts.
 24

Digest strategies
Follow the strategies described in understanding section.

Expand strategies
Go back to material and correct your understanding, expand on the
recalled material, store important information, ask and answer
specific questions in 3 categories:
1. Imagine you could talk to the author, what questions would you
ask? What criticisms would you raise?
2. How can the material be applied?
3. How could you make the material more understandable and
interesting to other students?

Review strategy
• Look at the effectiveness of your studying
• Identify errors and determine underlying causes, so that you can
modify study methods.

B. Strategies for retrieval and utilization

How to move all this new material into long-term memory so you can
find it again…

Strategy Explanation
the requirements of the task: use the comprehension-
retention strategies focusing on test questions.
Understand
Paraphrase. Image. Use problem-solving techniques
(break material down into parts and make connections).
 25

main ideas relevant to the task requirement. Look at

retrieval process as problem-solving process. What's the
Recall difference between your present state of knowledge and
your goal state? Set up reasonable sub-goals to get you
there.
the main ideas with specifics, after recall of the main
Detail
ideas, just fill in with details.
This phase organizes the information pulled together
Expand
during recall and detail.
Translate the information/material into your own prose

Review Schedule your periodic review: 24 hours, 7 days, 28

days later to make it part of your long-term memory. You
must use information to retain it!

C. Environmental Strategies to enhance learning

• Goal Setting and scheduling

Set daily, weekly, and semester goals, you need to schedule time to
study, review, and plan, especially long term projects. 


Use a workbook to set...

• Career goals then skill-oriented sub-goals (that are prerequisite to

reaching the 

career goals) 


• concrete goals for each semester and/or block, and a weekly

activity schedule. 


• Concentration management

Two problem sources are attitude problems and problems coping with
distractions:
 26

• Attitude problems. When setting the mood to study, learn to

monitor your negative and positive self-talk along with the images
created. Stop the negative self-talk spiral before it gains
momentum.


• Follow your negative thoughts to their logical conclusion in an

attempt to bring emotion in line with reality. 


• Practice relaxation techniques. In a relaxed state create mental

images of yourself successfully coping with the learning
distractions, and replace the negative self-talk with more positive
thoughts, and successful outcomes. 


• Use your learning issues


• List your questions and what you want to learn

• Keep a running learning issues list like a "to do" list
• Identify the depth and level of understanding you have of the
learning issue

• Review the list regularly to see how much progress you have
made, it helps overcome any discouragement you may have. 


• Elaboration Techniques for

Learning
Elaboration techniques are used to remember new material and
commit the information to long-term memory. There are several kinds
of elaboration techniques, choose one that suits your needs.
 27

Visual Elaboration: Develop skill in forming visual images by

highlighting new material, including concepts, facts and formulas,
making sure:

• The image is clear, striking, vivid and detailed


• The image has real meaning


• The image has some activity, energy, movement, and interaction 


• The image relates back to the main idea of the lesson


• The image shows how main concepts are related


Verbal Elaboration: Connect new material to understanding and long-

term memory by focusing more on language elements, using these
triggers:

• Is this material related to something I already know?

• Relate the material to personal beliefs, values, experiences, attitudes
• Think about the implications of the material
• Compare and contrast parts of the material
• Invent stories or sentences, relate parts to other parts.
• Connect information to the main idea
!

!! Strategies:

• Use analogies: What is this information like? 


 28

• Use transformations, paraphrase the information in your own words


• Teach someone else the new material

Organization Strategies: Use whatever works in each learning

situation.

• Use outlining, highlighting, underlining


• Tree diagrams (or other representations)


• Use charts, graphs. 


• Concept maps--use to relate concepts, especially relationships

between concepts 


• Any kind of schematic to reflect the main idea




• Tips for Specific Learning

Situations
Lecture

Get the most out of class lectures:

• Read about the material ahead of time!! 

 29

• Look for an overview at the beginning of the lecture. This will help
you organize your thoughts and take better notes--which will assist
with long-term retention of the new material. Create a "concept
map" (See page 30) of these major concepts to direct your note
taking and review sessions. 


• Deductive framework: In these lectures the “general statement of

law or principle” is presented at the beginning, and followed with
the related and consequent sub-material. The instructor provides the
framework for the presentation of material. 


• Inductive framework: In these lectures the “general statement of law

or principle” is presented last, after a series of statements leading
toward the concluding general law. Here, you must construct your
own framework, this demands much more attentiveness on your
part. Using the classic scientific model, the lecturer proposes a link
between discussed examples, and tests the suggestion with known
facts and evidence, proposing a hypothesis, and works to determine
if it is supported by evidence. At the conclusion of a question/
answer/discussion session, a general statement of law or principle is
the concluding remark.

Discussion

Get the most out of class discussion:

• Read the text. Prepare for class discussions. Try to make the text
material relevant to you. 


• Preparation. Find out what the discussion will cover in advance so

you know what to look for in the readings. 

 30

• Clarity of Purpose. Try to stay focused on an identifiable problem or

issue. When reading course material, identify components of an
argument while you have the original material in front of you; look
for differing opinions. Try to identify the values, beliefs, feelings
associated with students'different perspectives. 


• Common Focus. Bring books, handouts, outlines to class with you.

If the instructor prepares quotes, overheads, outlines, use this
information to focus your ideas in class. Materials the instructor
brings to class are a clue to what he/she believes is important. 


• Refer to your text. Use the textbooks and handouts as resources;

refer to them often to clarify your thoughts and backup your
arguments. 


• Summaries. Watch for instructor summaries of discussions to

validate what you think was said and organize your thoughts for
further discussion. 


Lab Work
Tips for successful completion of lab assignments:

• Use the scientific process skills of hypothesis formation,

identification, and manipulation of experimental variables, and the
process of inferring from data. 


• You can learn to improve operational thought through “inquiry-

based, hands on approaches” to laboratory investigation. Begin with
concrete examples and move toward the general abstract
understanding of basic principles. 

 31

• Rephrase the assignment. Learn to rephrase the assignment in your

own words to truly understand what is needed. 


• Look for meaningful patterns. Learn to summarize data, look for

patterns, infer from the data collected whether the hypothesis can
be accepted or rejected; and to identify extrapolation questions,
such as generalizations, and implications. What do the results really
mean?

Experiential Learning


Experiential learning takes its thrust from the constructivist model

which describes the learning process as one of constructing one’s
own knowledge. Through the process of active involvement in the
learning process, you gain greater depth and usefulness of learning. In
other words, the knowledge is created by the learner. In contrast, the
didactic method can be characterized as the instructor imparting
knowledge to the learner.
Experiential learning:

• Allows you to discover for yourself, gaining a sense of ownership

and increasing the likelihood that you will actually use what you
learn outside of class. 


• Creates awareness of the process of learning, which leads to the

probability of lifelong learning abilities. 


• Allows you to appreciate the contributions of all learning styles, as

well as the learning dimensions of behavior, intellect, and feeling.
 32

Cooperative Learning/Study Groups

Characteristics of cooperative study groups:

• Small study groups are self-selected. 


• It may be easier to learn difficult new material with others in a

group situation. 


• Groups work especially well for test review. 


• The discovery method of learning depends on an integration of

knowledge. The variety of backgrounds and learning styles inherent
to group study can support this process. 


• Students can quiz one another:

A. In what way does this information increase your ability to

function?

B. How does this new material relate to what you already know?

C. How will this information impact your interaction with patients? 


Some guidelines:

• Each person comes prepared--having read the text and outlined

important points. 

 33

• Each person prepares 15-20 quiz questions ahead of time. 


• Group study is best used as “drill time.” 


• Attend learning and study groups for clarification of subject content,

and skills practice. 


• Small Group Tutorials

Problem-based learning (PBL), as practiced in the medical school
curriculum, grew out of a cognitive psychology framework with its
emphasis on constructivist, student centered learning.
In cognitive psychology and PBL, instructional strategies integrate
concepts such as linkage to prior knowledge, contextual learning,
discussion and dialogue as learning tools, constructing learning, use
of instructional scaffolding, and the primacy of metacognitive
knowledge as a fundamental tool for lifelong self-regulated learning.
Training in medicine has reached such a high level of complexity that
an effective integrative strategy is necessary to ensure adequate
coverage and deep learning in both basic science and clinical skill
development. Student-centered, problem-based learning is a teaching
and learning strategy which has wide application due to its
effectiveness in helping integrate complex primary data, learning of
problem solving techniques for clinical practice, integrating medical
science across disciplines in a systems understanding of medical
functioning, as well as life-long independent learning skills.
In tutorials, you will use a simulated or actual clinical case scenario,
described in the context of medical practice, as a starting point for
self-directed learning with small discussion groups. Using adult
learning theory as the framework, you are encouraged to follow these
steps in a PBL session:
 34

1. Given a written description of a clinical condition, identify the

problem(s).
2. Propose hypotheses to explain the condition identified. In this
step, you recall prior knowledge, brainstorm or brainstream
possible hypotheses to explain the clinical condition, question
each other to clarify statements. Explain the mechanisms
underlying the proposed hypotheses. 


3. Explore what you already know, use it to make lists of questions

that can't be answered at this time for which self-directed study
will be helpful. 


4. Identify needed information such as clinical history, physical, lab

and x-ray data. 


5. During discussions you will identify learning issues. These are

areas of basic science, clinical knowledge and medical
procedures beyond your (the group’s) present understanding that
will then be researched, learned, and discussed in the group. All
members of the group identify, prioritize, and share the key
learning issues for research, study and understanding. These
learning issues may or may not be addressed in the next tutorial
session.

6. New information brought forward through studying the learning

issues is systematically applied to the clinical problem and
discussed, through several cycles to arrive at an eventual
conclusion to the particular case. New learning issues emerge as
information is discussed in the group.

The faculty tutors guide you through this process, allowing group
members to identify learning issues. The tutor role includes
maintenance of group cohesion and functioning, ensuring full group
 35

participation, focusing the discussion on important aspects of the

clinical problem, answering technical questions to move the
discussion along, and importantly, offering the scaffolding to move
learning toward integration of important aspects of basic and clinical
science that will explain the medical processes you study and answer
the clinical questions emerging from the tutorial case study.

• Concept Mapping
Concept mapping is a learning, organizing and review tool that
emphasizes the relationship between concepts. This is important
because medical knowledge and training draws from multiple
sources, the different basic science disciplines, clinical practice, and
communication. To fully appreciate this complexity inherent in
medical training, clinical case studies are used to demonstrate the
relationships between basic and clinical science. Concept maps can
be used from the beginning of medical school to illustrate concepts
and the relationships between concepts. This is an excellent way to
purposefully "chunk" information and related concepts for more
thorough understanding and for better long term memory and recall.
Concept mapping and diagramming may be something you have
already used; continuing this technique purposefully and consistently
can also be helpful in medical school. Maps can be constructed any
way you like, using concepts and factual information important to
you, with relationships between concepts drawn by you reflecting
what is important to your thinking and learning style.
Making the maps or diagrams yourself necessitates a thought process
that allows for in- depth learning, new information is more likely to
move into your long-term memory, and will still be easier to retrieve
in a more complete way later on.
Your map can be drawn with as much detail as suits your needs, from
broad maps that outline major concepts to very detailed maps
showing cause and effect relationships. Newer, more complex subject
areas may warrant several maps with varying degrees of specificity,
 36

where other, more familiar subjects can be adequately illustrated with

less detail.

Tips for constructing concept maps

• Select a topic 


• Identify the major concepts 


• Rank the concepts from general to specific 


• Start with the most general concept at the top, then spread out to
supporting concepts with circles or squares 


• Show linked and/or causal relationships by connecting the

appropriate concept circles or squares 


• Elaborate by naming the kind of relationship between concepts on

the connecting line, or using arrows to indicate direction of
relationship 


• Leave room to add detail over time


 37

• Semantic Qualifiers
& "Semantically Competent Clinicians"

Learn to use "semantic qualifiers": This involves learning to use

precise quantifiable language in the clinical setting to communicate
patient information. For example, instead of "pain in the right knee"
you would use "mono-articular" pain and instead of "pain in joints"
you would use "poly-articular" pain, and for "both knees" you would
use "bilateral."
Semantic qualifiers are "qualitative abstractions of the signs and
symptoms of a case in which an opposing abstraction is either explicit
or implicit."
The idea is to develop skill in clarifying and quantifying patient
symptoms in order to develop better diagnostic skill. Use of specific
terminology that distinguishes symptoms helps to clearly represent
the clinical situation in your mind, allowing for clear communication
of those representations during clinical case presentation. (Bordage,
2002)
Example 1:
"pain over the last two months" could be described as gradual onset
(vs. sudden onset)
Example 2:
"the pain is in my second and fourth fingers on both hands" might be
characterized as pain that is symmetrical (vs. asymmetrical) in the
MCP and PIP joints, mostly small joints (vs. large). (Bordage, 2002)
Example 3:
"Mr. Clark, a 35-yr nurse, previously in good health presented with a
first, acute episode of severe (7/10), right-sided low back pain of
recent onset (24 hrs) constant and sharp, that occurred on exertion
 38

immediately after lifting a patient from bed. The pain radiates below
the knee, to the right lateral part of the leg, the medial part of the foot,
and to the great toe."*
The underlined descriptors noted above are focused, show
transformations, follow the (clinical) reasoning, and use comparing
and contrasting.
Semantic qualifiers are distinguished by these characteristics: (see
examples below)

• They are more abstract 


• They have built-in oppositions 


• They are used to build problem representation 


• They are a means to access and compare and contrast relevant

diagnoses 


Some examples of semantic qualifiers: 


Patient
Male Female
Characteristics
Short
Tall

Chronology Acute Chronic

Immediate,
Delayed, postponed
spontaneous
New, first time, Second, third, relapse,
initial recurrence, flare up
Morning Evening
Sudden, abrupt Gradual, progressive
 39

Location Anterior (site) Posterior (site)

Facial Truncular
Intra, within Extra, outside

Quality Active Passive, latent

Apparent, visible Insidious, invisible
Burning Crushing
Full Empty, hollow
Greasy Dry

• Test Taking Strategies & Tips

Test Taking Strategies
Standardized exams are useful in that the scores allow you to see
where you stand among your peers, at medical school and nationally.
You can gauge your progress through medical school, and monitor
and adjust your learning strategies appropriately. There are many
assessments throughout medical school, both evaluating your
command of course content and evaluating faculty members'
teaching performance and the medical school curriculum process.
Assessment and evaluation is the basic method for knowing where we
stand, academically and in providing the academic environment. For
these reasons, you might as well embrace both the formative and
summative examinations offered throughout your medical training,
and learn to use the results pro-actively and constructively.
 40

Test Taking Tips

• Practice, practice, practice 


• Study what you don't know first 


• Take a simulated exam when possible and appropriate 


• Plan your study periods 


Use positive self-talk

• B-R-E-A-T-H-E

• To Review: General Tips

Tips for students Comments
Take the time to integrate new
Don’t cram, review daily.
material with what is already known.
Consciously relate new material to
old.

How does the medical school
Use elaboration techniques.
curriculum build upon the academic
foundation already established? Know
your science!
Keep your end goal in mind.

Make new material
Ask: How will this help me reach my
meaningful to you.
goal?
 41

Calculations, problems, terminology,

Practice, review, practice, essay questions, verbal clinical
review... communications; practice and
rehearse everything.
Start heavy studying early in the
Start strong--it is very difficult semester, then let up later if possible.
to catch up. It is much easier than trying to catch
up.
Learn relaxation techniques
Some stress can be motivational, too
and apply them when
much stress limits your ability to
studying and before taking
perform and accomplish.
tests.

• Additional Points to Ponder

• Students, Stress and Learning 


• Test and other Anxiety 


• Learning Disability 


• Intercultural Communication


• Glossary 

 42

• Students, Stress & Learning

Learning in the medical school environment is full of pressure to
perform and to coordinate a seemingly endless series of competing
responsibilities. Stress can be a great motivator, but finding the right
balance for competing interests can become a continuous struggle.

Balance lies with maintaining a learning environment that is
challenging but not threatening.
Fellow students, faculty and advisement staff can play a role in
creating this positive environment. Either too much or too little stress
can inhibit learning, remember that stress is defined differently for
everyone. Ineffective stress control mechanisms are often employed,
however, because of a lack of understanding combined with a lack of
confidence in an ability to perform. “Defensive avoidance” is a
common practice: where you avoid studying and avoid completing
assignments in order to reduce stress. A helpful intervention for
defensive avoidance is “stress inoculation” whereby you make sure to
have all course materials, timelines, and due dates, so that you know
what to expect; also look for timely feedback on your performance
and progress, which will result in a feeling of some control over
course activities.
Ask for this information if it is not immediately made available to you.
Much course material is available on course web sites, but there is
little substitution for a face-to-face visit with your instructor.

• Test & Other Anxiety

Test, or performance anxiety, is often related to inadequate course
work preparation. Along with improved study habits, time
management, and monitoring of self talk, you can develop specific
skills for coping directly with this anxiety. The anxiety spiral is
controlled through specific behavioral and cognitive techniques.
 43

I. Understanding the anxiety spiral process



Effective strategies for recognizing and controlling the anxiety spiral:
1. Bibliotherapy
Read books and articles describing the phenomenon of test anxiety.

Naming an emotional overload is often more than half the battle, as
well as understanding that your condition is normal and shared by
many other students. When you learn to identify and control your self
talk, you are well on the way to overcoming your anxiety.

2. Early Detection Training

• Situational Cues.
You can learn to improve your ability to identify

conditions when problems are likely to occur. “Awareness that they
are entering a troublesome situation can then cue them to begin using
or preparing to use coping strategies.”

• Physiological Cues
Identified and learned through discussions, homework exercises,
monitoring, role playing, and imagery exercises. These cues can help
you learn to “tune into what happens early in the anxiety spiral that
can be a tip that anxiety is mounting.”
Common cues: “Butterflies” in stomach; fast heart rate; cold hands;
perspiration; dry mouth; tense skeletal muscles, especially in the face,
neck, shoulders, back, and stomach. Learn to tune

 44

in to these changes, and adjust your behavior appropriately, as with

relaxation exercises.

• Cognitive Cues
This refers to an awareness of thought patterns that are associated
with spiraling emotions. Sometimes the unproductive or even
negative thoughts can be identified before the physiological
symptoms occur.

• Behavioral Cues
Certain behaviors are themselves the result of a spiraling string of
emotions.
For example:
- anxiety about being evaluated might lead you to avoid all instances
where this may occur, such as public speaking, tests, writing
assignments. 


- learn to recognize these avoidance behaviors, letting them serve as

a cue to begin coping strategies. 


II. Beck’s Three-Tiered Approach to dealing with Irrational

Beliefs
According to Albert Ellis, irrational beliefs are often at the root of
anxiety, especially for students. Irrational beliefs are illogical and
exaggerated thoughts including extreme and absolute words, such as:

Irrational belief Description

Over generalization “the idea will never work”
 45

something is wrong with___because of

Arbitrary influences
_____
Catastrophizing “I’m just a failure”
Two-sided reasoning statements just don’t connect
“I’ve seen it work before, I’ll just keep
Over socialization
trying.”
Negative thinking “I’m just no good.”

Self-talk is an important element underlying the experience of

anxiety. Once you learn to recognize negative or non-productive
thought process, you can use Beck’s three-tiered method to alter the
pattern.

Step 1: Learn to recognize a negative thought process.

Step 2: Identify faulty reasoning patterns in the automatic thoughts.
For example:
dichotomous thinking: thinking in black or white, i.e. total success or
failure over generalization: difficulty with one test question means
they will not be able to finish the whole test
Step 3: Then learn to control your thinking by stopping the automatic
thoughts

and thinking errors and identifying faulty thought themes. This is
accomplished by use of the “what would it mean to you.....”
technique to draw out your belief system. What are the worst possible
outcomes? As diagramed below.

Point A Point B Point C

Event:
Belief System: (automatic Consequent
Anticipating thoughts) Feelings:
something will
What if...then...then....then. Anxiety
happen...
 46

• Learn to reorient your thinking to more positive expectations 


• Humor can be useful to aid in changed thinking 


• Relaxation training is also useful to calm the anxiety so you can

focus on the present. 


• Remember: It is important to find a coping strategy that works for

you, own that method and use it appropriately. 


• Learning Disability


Formal Definition: A permanent neurological disorder that affects the
manner in which information is taken in or received, organized and
remembered, and then retrieved or expressed.



What this means for you as a student

Learning disabilities may surface in an educational setting through the

basic functions such as memory, oral expression, comprehension in
lecture format, organization of thoughts and concepts, and retrieving
information and expressing knowledge either verbally or in writing.
These processes show up in all academic areas of reading, writing,
spelling, logical reasoning, math, oral communications.



True learning disabilities do not go away, however, inconsistencies
are common as students learn over time to compensate for their
individual differences. To fit the diagnostic criteria for a learning
disability, intelligence must be measured at average or above.
 47

Disability does not prevent learning, although some students may

need special accommodations. All academic areas are usually not
affected, as students may show strength in some areas and weakness
in others. For example, a student may be strong in math, but weak in
reading comprehension and writing, or may understand concepts
well but do poorly on tests.

Indicators that could suggest the presence of a learning disability

Indicators are varied and individual, some may include: working hard
in class and feeling you know the material, yet still doing poorly on
tests; consistently overloading on course schedule, or taking courses
without planning; poor self management skills; repeating classes,
withdrawing from or taking incomplete in many courses; high levels
of test anxiety, finding there is not enough time to complete tests;
academic history of special education support; anger and frustration
because of spending large amounts of study time with lower results
than peers.
What kinds of help are available?
You are the best source of information on your learning needs. Some
accommodations are simple: additional time for academic tasks, help
with providing alternate formats for studying options.

• Intercultural Communication
1. What is communication?

Communication is a process involving the exchange of information.

Successful communication requires a transmission of meaning, and
that understanding and acceptance also occur. The role of receiver
and sender is interchangeable because the roles keep changing and
interchanging. Because the ultimate goal of communication is
acceptance of the message, some modification of original message,
using feedback both on the part of the receiver and the sender may
 48

occur. This is especially true of cross cultural communication.


It is essential that you check for meaning and understanding.

2. Communication and the classroom

Communication is natural among people but misunderstandings are

common. The 43 classroom is one of the worst places for
misunderstanding to occur. According to Stanley (1987) disastrous
consequences may occur, such as: damaged relationships between
learner and instructor, loss of confidence in the learner, loss of the
instructor’s credibility, and confusion, disappointment, or despair on
both sides.
Communication Style: Learner and Instructor
It is important to realize that the communication style of your
instructor can conflict with your preferred communication style.
For example, important differences can include:

• Wait time between utterances (how fast or slow do you talk?) 


• How a person gains attention 


• How a person acknowledges that a message has been understood 


(verbal, and non-verbal) 


• How people take turns in a conversation 


Pay attention to both classroom and tutorial communications,

between faculty and fellow students. Miscues can lead to
inappropriate responses on the part of both students and instructor, a
seeming uncooperative atmosphere, and subsequent potential for lack
of respect. Whereas good communication can build trust, shared
decision-making, good peer learning and teaching, and confident
learners. 

 49

3. Barriers to effective communication

Stanley (1987) describes some barriers to effective communication in

the classroom:

• Poor listening
On the part of instructor (sender) or student (listener). 


• Information overload
Student or instructor (receiver) may become overloaded with
information and the pace of presentation. 


• Poor sequencing of presentation

A jumbled presentation can interrupt the learner’s concentration. 


• Semantics
The use of language without precise meaning. A lack of clarity in
presentation. Statements that are too general may cause
misunderstandings of content. 


• Distancing
The instructor may appear too distant from learners. A
misunderstanding of intention may result in loss of content on the part
of learners. 


• Mental set and trained incapacities

The practice of selective retention on the part of learners. People tend
to retain information that relates to something they already know, or
that fits their belief or mental system by training. 


• Anxiety and fear

 50

This is especially true of learners that have been out of the classroom 


• Lack of interest
A problem of motivation for the subject content. 


• Outside distraction
Problems with the learning environment. 


• Lack of background information

This involves learner characteristics that can impact your learning. 


• Self Concept/Self Image

Learner and instructor comparing themselves to one another and
forming judgments can affect communication in the learning
environment. Conflict may arise if the learner feels threatened by the
instructor’s attitude, expectations, or classroom communication style.


4. Intercultural Communication
Defining culture: A social system consisting of learned behaviors,
artistic traditions, technological achievements, communicative
techniques, religious beliefs, philosophical concepts, even genetic
characteristics.
Defining intercultural communication: Interaction between members
of differing cultures, creating the possibility that the value systems of
the interacting members are so different that real understanding is
quite difficult.
Elements of communication that may be affected by culture:
Perception, information retention, pitch, articulation, intelligibility,
 51

translation, and dialect.


Non-verbal factors in intercultural communication.

Personal space: that distance characteristically kept between people
in various cultures; symbolic of the nature & extent of relationships
between people.
Smile: shows pleasure, almost universal in meaning (also frowns), can
also be used to indicate scorn, ridicule, or contempt. Can also signify
discomfort or embarrassment.
Posture: associated with a person’s frame of mind and general attitude
about themselves, varies by culture.
Smell: associated with type of food consumed, among other things.

Eye contact--very basic and varies by culture; can show respect either
looking straight at another or looking away depending on cultural
context.


Touch: specific to culture; closer personal space cultures touch more

to communicate.

5. Communication and medicine; cultural competence in

health care
Good communication between patient and health provider is
essential for providing and receiving good health care. The
practitioner brings a wealth of medical knowledge to the clinical
setting, but only the patient really knows what their symptoms are,
how long the duration and how intense, and other pertinent
diagnostic information. Patients need to feel comfortable in the health
care setting, in order to communicate freely and honestly with the
health practitioners. It can be helpful to verify communications and
ask patients what their concerns are, and to be aware of family needs.
 52

The achievement of good communication between patients, families,

and health providers, despite differences in ethnicity, language, or
health practice is known as cultural competence in providing health
care. As a medical student, you should understand how good
communication impacts the quality of health care delivery and
develop your awareness, through clinical experience, of how to
communicate well with your patients, whoever they are.

• Glossary
Term Definition
Means active listening, reading, and studying for
understanding, and taking an interactive role in the
Active Learning learning process. Student is proactive, completes
advanced preparation for class to discuss, analyze,
participate. Student centered.
Interaction between instructor/student, and student/
Cooperative
student that promotes learning, usually in a group
Learning
setting.
Equal The process of engaging and including all students as
Opportunity partners in the learning experience.
The interactive behaviors inherent in communication
Group Process among several individuals embarked upon a shared
purpose or goal.
A permanent neurological disorder that affects the
Learning manner in which information is taken in or received,
Disability organized and remembered, and then retrieved or
expressed.
Learning Process Reflection, trial and error, repetition.
 53

Reading, listening, writing, coding, mapping,

Learning Skill
memorizing.
An organized and purposeful approach to the learning
Learning Strategy
task.
The way a student learns best. Very individual. Could be
Learning Style a preference for kinesthetic, auditory, linguistic, or
visual ways of learning, among others.
The process of identifying one’s preferred style and best
Learning to Learn
strategy to use for each learning task.
Interactive between instructor and students. Both
students and instructor are active participants in the
Non-traditional
process of learning. Learning is self directed, as an
teaching methods.
active problem-solving orientation, instructor acts as
facilitator and coach.
Student listens to prepared and presented material, takes
Passive Learning
notes, and is tested on recall and understanding.
Traditional Lecture, class notes, review, test. Discussion centers
teaching methods. upon the instructor. Instructor centered.